HIV Prevention, treatment and care amongpeople who inject drugs

Fabienne Hariga, MD, MPHSenior HIV Adviser, UNODC Vienna

Co-sponsor

HIV among People who Use Drugs

HIV in Prison

Settings

CONVENING AGENCY

Prevalence of HIV among people who inject drugs12.7 million PWID (0.27 % )

1.7 million PWID living with HIV (13.1% of PWID)52% with hepatitis C

Source: World Drug report 2014

HIV AND PEOPLE WHO INJECT DRUGS IN PRISONS

JOINT UN RECOMMENDED INTERVENTIONSComprehensive Package of interventions for HIV prevention,

treatment and care among people who inject drugs

1. Needle and syringe programmes (NSPs)2. Opioid substitution therapy (OST) and other evidence-based drug

dependence treatment3. HIV testing and counselling (HTC)4. Antiretroviral therapy (ART)5. Prevention and treatment of sexually transmitted infections (STIs)6. Condom programmes for people who inject drugs and their sexual

partners7. Targeted information, education and communication (IEC) for

people who inject drugs and their sexual partners8. Prevention, vaccination, diagnosis and treatment for viral hepatitis9. Prevention, diagnosis and treatment of tuberculosis (TB).

Effectiveness of NSP Reduction in the rate of HIV transmission (and

HCV) Frequency of unsafe injection (risk HIV and HCV)

No initiation of injecting among people who have not injected previously

No increase in the duration or frequency of illicit drug use or drug injection

Allow for IEC Allow for referral to OST, HTC or ARV and TB

Reduce number of used syringes discarded in public areas

Bleach is not an effective alternative especially for Hepatitis C

HIV (and hepatitis C or B) is transmitted among people who inject drugs through sharing

injection equipment

Opioid use Frequency of injection & unsafe injection (risk HIV and

HCV) Risk of overdoses Risk of abortion/miscarriage of pregnant opiate dependent

women

Increase retention in drug dependence treatment Adherence to treatment (ARV , TB, Hepatitis C) Improve health status and wellbeing Social functioning Work and productivity and economic status

Criminal behaviour Recidivism Violence, drug seeking in prison

Reduction in the rate of HIV transmission (and HCV)

Effectiveness of OST

Why a comprehensive approach?

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

0

200000

400000

600000

800000

1000000

1200000

baseline substitution (only)

needle exhange only comprehensive harm reductions

Pe

op

le li

vin

g w

ith H

IV (

mill

ion

s)

Source: Sarkar et al, 2008

Universal Access

• Physically accessible – geographically distributed – Hard to reach location

• Affordable – patients should not have to pay for their treatment

• Equitable and non-discriminatory – no exclusion criteria except medical ones, e.g. – OST should not be limited to only those IDUs who are HIV infected or who

have failed on other drug dependence treatment– No compulsory treatment

• Non-rationed – supply should be determined by need: – e.g. needle and syringe programmes with strict limits on the number of

syringes provided to each client are less successful than those that do not impose such restrictions

HIV incidence

0

100

200

300

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500

600

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800

900

1000

New HIV Cases

PWID Incidence Rate

Nicolas Ritter, AFRAVIH 2014

Incidence du VIH à Maurice (2000-oct 2013)

NSP

PRINCIPLES

Prison health is public health Linkages with public health and

community programmes

Human rights based and gender sensitive Principle of equivalence Medical ethics No segregation of PLWH;

Criminal justice reforms to reduce the prison population Alternatives to imprisonment Reduce pre-trial incarceration End compulsory detention of drug users

and sex workers for “rehabilitation” Prison reforms

Ensure safe prison conditions Prevent violence Proper classification Conjugal visiting rooms

12

Harm reduction in prisons

New HIV Infections in Lithuanian prisons

Intervention Availability

NSP No

OST No

HIV Testing Yes

ARV Therapy 18%

Harm Reduction Education

5 pilot projects

Source: UNODC S. Rotberga, Tallinn, 2011

New HIV Infections in Spanish prisons

Intervention Availability

NSP Yes, 30 Prisons

OST10.2% of inmates (6,429 in 2010)

HIV Testing 76.10%

ARV Therapy64.6%

(2,668 in 2010)

Peer Health Education

100%

Increase of HIV in Lithuanian prisons in the absence of prevention services

Decrease of HIV in Spanish prisons in the presence of prevention services

Source: Enrique Acín García, M.D., Head of Public Health Department. General Secretariat of Penitentiary Institutions. Ministry of Interior. Spain.

3 1

10

28

0

5

10

15

20

25

30

2006 2007 2008 2009 2010 2011

Ne

w H

IV I

nfe

cti

on

s i

n P

ris

on

s (

#)

0.60%

0.70%

0.14%

0.15% 0.17%0.15%

0.06%

0.16%

0.09%

0.08%0%

in 20100.0%

0.1%

0.2%

0.3%

0.4%

0.5%

0.6%

0.7%

0.8%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

HIV

Pre

va

len

ce

in

Sp

an

ish

Pri

so

ns

(%

)

Stigma

Bottlenecks

Critical enablers

• Supportive legal and policy framework

• Supportive law enforcement practices

• Empowerment of people who use drugs

• Alternatives to imprisonment including decriminalisation of drug use

Appropriate funding

New publications:

• Police, HIV and PWID: a training manual

• Policy brief on HIV and women who inject drugs

• Handbook on needle and syringe programmes in prisons

…Unfortunately, many national drug control systems rely on sanctions and imprisonment, rather than evidence-based health care in full compliance with human rights standards …

          … These are major barriers to HIV and to harm reduction services, including in prisons and other closed settings…

UNAIDS Programme Coordinating Board,1

July 2014

Thank you!

Fabienne.Hariga@unodc.org

www.unodc.org